Health and Nutrition Questionnaire
The following information is confidential and will not be disclosed to anyone outside of this organisation.
Name
First name
Last name
Body information
Weight in kg
Height in cm
Date of birth
day / month / year
E-Mail
example@example.com
Gender
female / male / other
Phone number
-
area code
number
Are you a full-time athlete?
Professional dancer / Dancer in education / hobby dancer / other
Frequency of your exercise
times/week
Length of session
minutes/hour
Intensity
Light
Moderate
Hard
Would you like to lose weight?
Yes
No
Back
Next
Why are you reaching out to runamarie.diet?
Please indicate what you would like from the consultation
What is your estimate of your general health?
Excellent.
Good.
Fair.
Poor.
Do you have a food allergy?
celery, eggs, fish, lupin, milk, molluscs, mustard, peanuts, tree nuts, sesame, soybeans, other
Do you have a food intolerance?
celiac disease, lactose intolerance, fructose malabsorption, histamine intolerance, other
Do you follow a special diet?
vegan, vegetarian, low-carb, keto, intermittent fasting, other
Back
Next
Medical infomation - please tick the box if the following apply to you
Cancer
Heart disease
High blood pressure
Diabetes
Kidney disease
Liver disease
High cholesterol levels
Osteoporosis
Digestive disorders
Irritable stomach
Other
Do you have a family history of the above? If yes, please explain.
Yes / No / Explanation
Please list any medications you are currently taking and the reason for taking them.
Medication + reason
Do you take vitamin or mineral supplements? If so, list the type and amount.
Do you smoke? If so, list the type and amount
Please indicate the typical meals and snacks that you consume on an average day.
Breakfast
Snack
Lunch
Snack
Dinner
Snack
Signature
Submit
Should be Empty: